Hepatitis C

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Hepatitis C, the most serious form of hepatitis, affects approximately 4 million Americans; the true incidence is unknown, but it is estimated that there are between 35,000 and 185,000 new cases each year. According to the Centers for Disease Control and Prevention, 21 percent of all acute viral hepatitis in the United States may be attributed to hepatitis C infection. Hepatitis C is the most common blood-borne infection in the United States.

Infection with hepatitis C usually results in chronic hepatitis. Indeed, 75 percent to 85 percent of cases become chronic. Sixty-seven percent of all people with hepatitis C develop chronic liver disease, with an accompanying elevation of liver enzymes. If left untreated, hepatitis C may develop into cirrhosis of the liver (a hardening of the organ that reduces its ability to function), liver failure, and liver cancer. In fact, hepatitis C is a major contributing factor to liver cancer.

In most people infected with hepatitis C, there is evidence of the disease in both blood serum and liver tissue. Fifteen to 25 percent of acutely infected patients who recover from the illness may retain the hepatitis C viral antibodies for several years, whereas others will have no serological markers of the infection on extended follow-up.

Although once an important cause of transmission, since 1992 blood transfusions have been screened and no longer cause Hepatitis C infection. Illicit drug use now causes most  cases. Other high-risk behaviors, including intranasal cocaine use, tattoos, body piercing, or frequent exposure to blood (as in war) may also cause HCV infection if instruments are not sterilized between use. Sexual transmission may also occur. Rarely, healthcare workers are infected when they're exposed to infected patients. There is also transmission from mother to infant when infected mothers give birth. In some instances there is no obvious risk factor.

A relatively new, two-drug regimen has increased the effectiveness of treatment for hepatitis C. A decade ago, as few as 10 percent of people were cured; now the figure is 40 percent. Better management of the side effects of treatment has also enhanced the medical community's ability to deal with this chronic illness.  Even more exciting are new medicines currently under testing that will further improve treatment effectiveness. This section contains additional explanations of hepatitis C. It also discusses:

  • Need-to-know anatomy
  • Causes
  • Risk factors
  • Complications
  • Need-to-Know Anatomy

    The liver is an organ essential to life. It is about the size of a football, and it weighs about 3 pounds in women and 4 pounds in men. It is located underneath the ribs and extends horizontally from the middle of the body to the right side. Its surface is smooth and convex. It consists of a myriad of microscopic units called lobules.

    The liver stores vitamins, sugar, and iron. It controls production and removal of cholesterol. It clears the body of wastes and poisons and removes bacteria from the bloodstream to combat infection. It releases bile, a substance necessary for digestion and absorption of key nutrients. In addition, it converts nutrients into clotting factors, to stop bleeding, and immune factors to fight foreign invaders.

    If the liver fails, a person can live only a day or two. But if even as much as 75 percent to 80 percent of it is removed or destroyed acutely in a healthy individual, the liver can grow new, healthy liver cells and continue to perform its essential functions.

    Causes

    Hepatitis C is transmitted through contact with infected blood and other body fluids. Some studies of hepatitis C have focused on blood transfusion as the major source of viral transmission. However, research now indicates that most infections are acquired in other ways: illegal drug use by injection, exposure to infected blood in the workplace, sexual or household contacts with infected people (sharing of personal care items such as a toothbrush, razor, or nail file), and transmission from mother to infant when infected mothers give birth, for example.

    Risk Factors

    The risk of contracting hepatitis C infection is greater when infected blood or bodily fluids can readily be exchanged. Risky behaviors and situations include:

    Drug use: Drug users who inject their drugs, particularly those who share needles, are at very high risk of contracting hepatitis C. Drug use by injection has become the predominant risk factor for contracting a hepatitis C infection. However, intranasal cocaine, heroin, or methamphetamine ingestion also enhances the risk of contacting hepatitis C as the straws used may be contaminated with infected blood or mucus.

    Risky sex: Engaging in intercourse with multiple sexual partners or in sex without a condom increases the risk. Men who have sex with men are also at greater risk of hepatitis C infections.

    Healthcare employment: Doctors, nurses, first responders, emergency technicians, or other health and emergency workers who are exposed to blood are at heightened risk of infection.

    Kidney disease: Patients with kidney disease and undergoing hemodialysis are at increased risk of infection.

    Household contact with infected person: Living with someone who has chronic hepatitis C may result in infection, particularly if sharing nonsterilized personal care items that may be contaminated with infected blood or fluids.

    Involvement with war and natural disasters: War and natural disasters may expose individuals to contaminated blood and fluids. Vietnam-era veterans have high rates of hepatitis C, in part because they received transfusions at a time when the blood supply was not screened for the hepatitis C virus.

    Tattoos and piercings: The use of improperly sterilized equipment can lead to hepatitis C infection. However, when these procedures are done in licensed settings with good infection control practices, they do not transmit HCV.

    Complications of Hepatitis C

    Serious complications of chronic hepatitis C, which may eventually require liver transplantation, include cirrhosis and liver cancer. Chronic hepatitis C-induced cirrhosis is the leading indication for liver transplantation in the United States.

    Cirrhosis

    Cirrhosis of the liver is a condition in which scar tissue replaces normal, healthy tissue, blocking the flow of blood through the organ and preventing it from functioning. Cirrhosis is the 12th leading cause of death by disease, killing about 26,000 people each year. The hepatitis C virus ranks with alcohol as a major cause of cirrhosis in the United States.

    In the early stages of the disease, cirrhosis may cause no symptoms. But as scar tissue replaces healthy tissue and liver function fails, the following symptoms are common: exhaustion, loss of appetite, nausea, weakness, weight loss, abdominal pain, swelling in the legs and abdomen, bruising and bleeding under the skin, jaundice (yellowed skin and eyes), confusion, difficulty concentrating, memory loss, muscle loss, and itchy skin. Cirrhosis may result in resistance to insulin, leading to type 2 diabetes.

    As the disease progresses, blood flow in the intestines, spleen, stomach, and esophagus is slowed, leading to a condition called portal hypertension, where pressure in the portal vein is too high. As a result, blood vessels in the stomach and esophagus can burst, causing a serious bleeding problem. As toxins build up in the blood and brain because the liver can no longer remove them, mental functioning declines and personality changes, coma, and death may result.

    Ultimately, cirrhosis can lead to hepatocellular carcinoma, a type of liver cancer. The risk of developing this cancer is three to four times as high in patients with cirrhosis as in those with chronic hepatitis C but without cirrhosis.

    Liver Cancer

    Chronic hepatitis C infections are an important cause of hepatocellular carcinoma, or primary liver cancer, throughout the world. In the United States, hepatocellular carcinoma is responsible for over 12,000 deaths per year. Worldwide, it causes over a million deaths per year, making it one of the most common malignancies in adults. It is more common in men than women, and in blacks than whites. It is especially prevalent in parts of Asia and Africa, although it is related to endemic hepatitis B infection and environmental exposures in those regions. In the United States, HCV contributes to most cases of primary liver cancer—that is, cancer that begins in the liver.

    Alcohol appears to play a role in the development of liver cancer in patients with hepatitis C. Whether this is related to a more aggressive disease because of a combination of hepatitis C virus and alcohol or whether alcohol is an independent factor remains unknown.

    In the United States, primary liver cancer is often detected during screening for underlying liver disease. Most people with liver cancer have no symptoms until the disease is advanced. Later stages of liver cancer, when the cancer is very large or when it impairs the functions of the liver, can produce more obvious symptoms such as abdominal pain, weight loss, lack of appetite, and finally jaundice and abdominal swelling.

    Most hepatocellular carcinomas are first diagnosed with CT scans, magnetic resonance imaging, or ultrasound scans. These tests range from 60 percent to 100 percent accuracy, depending on the size of the tumor, with larger tumors being more visible. About 70 percent of patients with hepatocellular carcinoma have elevated blood concentrations of a tumor marker called alpha-fetoprotein; however, it is not specific for this condition. If there is doubt about the presence of liver cancer, the definitive diagnosis is made by liver biopsy.

    Treatment of liver cancer is based on the size and location of the tumor, the spread of the cancer to blood vessels, and nearby or distant organs. Surgery, in which a portion of the liver is removed, or "resected," offers a potential cure for the disease and the best long-term chance of survival. Patients with smaller tumors and without cirrhosis or metastases to other organs are the best candidates for liver resection. New surgical techniques such as cryosurgery (freezing the tumor and tissue around it), radio-frequency ablation (destroying the tumor with a heat probe), or transarterial chemoembolization (TACE, in which chemotherapy drugs are injected directly into the tumor) may work for some patients who are not good candidates for liver resection.

    In patients with small tumors but advanced cirrhosis, liver transplantation offers the potential for cure and is the treatment of choice. The obvious benefit of transplantation is that it removes not only the tumor but the diseased liver as well. The cancer must be confined to the liver, without invasion into the surrounding blood vessels. The five-year survival rate after liver transplantation for small hepatocellular carcinomas is approximately 75 percent. Patients with large (more than 5 to 6 centimeters) or more extensive tumors have a high risk for early recurrence after liver transplantation and therefore are not candidates. Patients with these types of tumors may be treated with embolization or ablation techniques.

    Traditional systemic chemotherapy and radiation are not effective for treating liver cancer.

    Early detection of liver cancer improves the chances of survival after treatment. Many patients with chronic hepatitis B should undergo liver cancer screening with a liver ultrasound, CT scan, or MRI beginning at about age 30-40. Asians, Asian-Americans, and native Africans, who may develop chronic hepatitis B infections at birth, have a high risk of liver cancer at an early age. The risk is greater in men and those with a family history of liver cancer. Universal hepatitis B vaccination may ultimately reduce the incidence of this cancer worldwide.

    All patients with cirrhosis from any cause (including hepatitis C) should be screened for liver cancer with imaging of the abdomen every six to 12 months. Other than antiviral therapy, there is no effective strategy to decrease the risk of developing liver cancer. Thus, early detection through repetitive screening is of paramount importance.

    Last reviewed on 7/21/09

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